Effective March 3, 2025, New Level of Care (LOC) Review Process for Inpatient NICU Authorizations (MD Only Facilities)
At CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (BlueChoice), ensuring our members are consistently receiving the right care at the right time and the right level is our priority. Effective August 1, 2024, we introduced updated requirements for inpatient and observations stays. These requirements are included in the Inpatient and Observation Care Notification Requirements Payment Policy located within the Payment Policy Reference Manual, and announced in the April and June BlueLink Newsletters as well as in Provider News emails sent on May 2, 2024 and July 23, 2024.
Level of Care Required on Inpatient Requests
One of the key requirements of the Inpatient and Observation Care Notification Requirements Policy is to ensure providers are including level of care information on all inpatient requests. To indicate the level of care information, providers are including the appropriate revenue code as part of the request they submit to CareFirst.
What will change effective March 3, 2025?
Beginning March 3, 2025, CareFirst will review prior authorization requests for inpatient NICU admissions to ensure that all services are an appropriate duration and level of care as documented in the Level of Care Authorization – Facility (Maryland only) Payment Policy located within the Payment Policy Reference Manual page on the CareFirst Provider Website.
- Note: A link to the Payment Policy Reference Manual is also available on the CareFirst BlueCross BlueShield Community Health Plan Maryland (CareFirst CHPMD) and CareFirst BlueCross BlueShield DualPrime(HMO-SNP)provider websites.
How will the level of care review process work?
Clinical documentation of ongoing hospitalizations will be reviewed concurrently, in most cases, to substantiate the level of care.
- If it is determined that the reported level of care does not meet the established MCG Clinical criteria, a denial for the bed day or authorization request will be issued.
- The following criteria will be utilized when reviewing level of care for NICU:
- LOC-010 – Intensity of Care Criteria 1 – Routine Care
- LOC-010 – Intensity of Care Criteria 2 – Continuing Care
- LOC-010 – Intensity of Care Criteria 3 – Intermediate Care
- LOC-010 – Intensity of Care Criteria 4 – Intensive Care
- Access the MCG Clinical Criteria Tool Instructions tutorial for more information on how to utilize this resource.
- The following criteria will be utilized when reviewing level of care for NICU:
- If the hospital agrees with the review assessment, the hospital may resubmit an authorization request with an updated level of care most consistent with the
guidelines for the specific dates of service in question. - If the hospital does not agree with the review assessment, it may request a peer-to-peer for reconsideration and/or follow the normal appeal process.
- The purpose of the peer-to-peer conversation is to allow the ordering or
treating provider an opportunity to discuss a pre-service adverse benefit
determination denial with a CareFirst Medical Director. This process is
available only when a pre-authorization request has been denied because
the service has been determined to not be medically necessary. The ordering
or treating provider can initiate the peer-to-peer discussion by calling the
Care Management Department at 410-528-7041. If the request is made after
five days of the adverse benefit determination denial, the provider should file an appeal.
- The purpose of the peer-to-peer conversation is to allow the ordering or
Which members will these changes impact?
These requirements apply to all CareFirst members admitted to a Maryland facility. This includes members covered under Commercial, Federal Employee Program (FEP), Medicare Advantage, CareFirst CHPMD (Medicaid), and CareFirst BlueCross BlueShield Advantage DualPrime lines of business.
Will the level of care review expand beyond NICU requests?
Yes. CareFirst will begin expanding its review of inpatient prior authorization requests for Intensive Care Unit (ICU) and Intermediate Care in Maryland Facilities beginning July 1, 2025, to ensure that all services are an appropriate duration and level of care.
Where can I find more information?
Additional information will be provided as we get closer to implementation. We will also be covering this topic during our upcoming live webinars in December. Click on one of the sessions below to register.
Hospital Quarterly Live Webinars
Will training resources be available?
Yes, please be on the lookout for additional communication about these requirements along with training resources that will be included on our Learning and Engagement Center as we get closer to March 3, 2025.